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Ebola Situation Report - 4 February 2015

SUMMARY

Weekly case incidence increased in all three countries for the first time this year. There were 124 new confirmed cases reported in the week to 1 February: 39 in Guinea, 5 in Liberia, and 80 in Sierra Leone.

Continued community resistance, increasing geographical spread in Guinea and widespread transmission in Sierra Leone, and a rise in incidence show that the EVD response still faces significant challenges.

As the wet season approaches, there is an urgent need to end the outbreak in as wide an area as possible, especially in remote areas that will become more difficult to access.

Guinea reported 39 new confirmed cases, compared with 30 the previous week. An unsafe burial that took place in early January in the eastern prefecture of Lola, on the border with Côte d’Ivoire, has so far resulted in an outbreak of 11 confirmed cases. A further confirmed case in the northern prefecture of Siguiri, on the border with Mali, also originated in Lola.

The north Guinean prefecture of Tougué, which also borders Mali, has reported its first 2 confirmed cases. Both cases originated in the western prefecture of Dubreka.

In light of the recent increase in cases in northern Guinea, cross-border meetings between Guinea, Mali, and Senegal are planned to strengthen coordination of surveillance. A rapid-response team has also arrived in the border area between Lola, Guinea, and Côte d’Ivoire to assess risk and strengthen surveillance.

A total of 80 new cases were reported in Sierra Leone in the week to 1 February, compared with 65 the previous week. The western districts of Port Loko and the capital Freetown are the worst-affected areas. Nine of 14 districts in the country reported at least 1 confirmed case, up from 7 districts in the previous week.

The target is for 100% of new cases to arise among registered contacts, so that each and every chain of transmission can be tracked and terminated. In Guinea in the week to 25 January, 14 of 26 (54%) new confirmed and probable cases in arose among registered contacts; in Liberia in the 9 days to 31 January, 7 of 7 (100%) new confirmed cases arose among registered contacts; and in Sierra Leone in the week to 18 January 26 of 121 (21%) confirmed cases arose among registered contacts.

The case fatality rate among hospitalized cases (calculated from all confirmed and probable hospitalized cases with a reported definitive outcome) is between 50% and 61% in the 3 intense-transmission countries.

A total of 822 confirmed health worker infections have been reported in the 3 intense-transmission countries; there have been 488 reported deaths.

A total of 10 of 34 prefectures in Guinea reported at least one security incident or other form of refusal to cooperate in the week to 1 February. No counties in Liberia and 3 districts in Sierra Leone reported at least one similar incident during the week to 27 January.

COUNTRIES WITH WIDESPREAD AND INTENSE TRANSMISSION

There have been almost 22 500 reported confirmed, probable, and suspected cases (Annex 1) of EVD in Guinea, Liberia and Sierra Leone (table 1), with almost 9000 reported deaths (outcomes for many cases are unknown). A total of 39 new confirmed cases were reported in Guinea, 5 in Liberia, and 80 in Sierra Leone in the 7 days to 1 February.

A stratified analysis of cumulative confirmed and probable cases indicates that the number of cases in males and females is similar (table 2). Compared with children (people aged 14 years and under), people aged 15 to 44 are approximately three times more likely to be affected. People aged 45 and over are almost four times more likely to be affected than are children.

A total of 822 confirmed health worker infections have been reported in the 3 intense-transmission countries; there have been 488 reported deaths (table 3).

Data are based on official information reported by ministries of health. These numbers are subject to change due to ongoing reclassification, retrospective investigation and availability of laboratory results. *Not reported due to the high proportion of probable and suspected cases that are reclassified. ‡ Data not available.

Table 3: Ebola virus disease infections in health workers in the three countries with intense transmission

Country

Cases

Deaths

Guinea

164

88

Liberia

371

179

Sierra Leone

287

221

Total

822

488

Data are confirmed cases and deaths only, apart from deaths in Sierra Leone, which include confirmed, probable, and suspected deaths.

Figure 1: Geographical distribution of new and total confirmed cases

The boundaries and names shown and the designations used on this map do not imply the expression of any opinion whatsoever on the part of the World Health Organization concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. Dotted and dashed lines on maps represent approximate border lines for which there may not yet be full agreement.

GUINEA

Key performance indicators for the EVD response in Guinea are shown in table 4.

A total of 39 confirmed cases were reported in the 7 days to 25 January 2015 (figure 2), compared with 30 the week before. This is the second week in a row that case incidence has increased in Guinea.

10 districts reported a confirmed or probable case during the reporting period (figure 2).

An unsafe burial that took place in early January in the eastern prefecture of Lola, on the border with Côte d’Ivoire, has so far resulted in an outbreak of 11 confirmed cases. A further confirmed case in the northern prefecture of Siguiri, on the border with Mali, also originated in Lola.

The north Guinean prefecture of Tougué, which also borders Mali, has reported its first 2 confirmed cases. Both cases are thought to have originated in the western prefecture of Dubreka.

In light of the recent increase in cases in northern Guinea, cross-border meetings between Guinea, Mali, and Senegal are planned to strengthen coordination of surveillance. A rapid-response team has also arrived in the border area between Lola and Côte d’Ivoire to assess risk and strengthen surveillance.

The western district of Forecariah, which borders the Sierra Leonean district of Kambia, remains the worst-affected district in Guinea, with 13 new confirmed cases in the week to 1 February.

The capital, Conakry, reported 6 confirmed cases (figure 2). 12 districts that have previously reported confirmed cases did not report any confirmed cases in the 21 days to 1 February; 4 have reported no cases for over 100 days (figure 1, figure 5).

The case fatality rate (CFR) during the month of December was 55%. Since the onset of the outbreak there has been significant geographical and temporal variation in CFR. For example, data from the Guinean capital Conakry suggest a cumulative CFR of just over 40%, compared with a cumulative CFR of just over 70% in the prefecture of Gueckedou. The underlying causes of these variations are not yet known. Gueckedou was particularly badly affected at the beginning of the outbreak, and there is anecdotal evidence that the CFR is now much lower than it was earlier in the epidemic.

Locations of the 5 operational, 4 planned laboratories in Guinea are shown in figure 7.

In the week to 25 January, 54% of new confirmed and probable cases arose among registered contacts; an increase from 30% the previous week. During the week to 1 February 2015, 91% of all registered contacts were seen on a daily basis.

A total of 8 deaths were reported in the community. Ideally all cases should be identified and treated in an Ebola-specific facility; there should be no EVD-related deaths in the community.

In the week to 1 February, 35 unsafe burials were reported.

Engaging effectively with communities continues to be a challenge in Guinea. Investigation of the recent burial-linked outbreak in Lola was initially hampered by community resistance, whilst resistance in Forecariah has also limited the effectiveness of response measures. In the week to 1 February, 10 prefectures in Guinea reported at least one instance of community resistance.

Guinea reported 2 new health worker infections in the week to 1 February.

LIBERIA

Key performance indicators for the EVD response in Liberia are shown in table 4.

A total of 5 confirmed cases were reported in the 7 days to 1 February (figure 3), compared with 4 cases the previous week.

All 5 confirmed cases were reported from Montserrado, the district that includes the capital, Monrovia (figure 1 and figure 3).

Nine districts in Liberia have not reported a confirmed case for over 42 days (figure 5).

Locations of the 18 operational Ebola treatment centres (ETCs) in Liberia are shown in figure 6.

Locations of the 9 operational laboratories in Liberia are shown in figure 7.

In the nine days to 31 January, all 7 (100%) of new confirmed cases arose among registered contacts; up from 50% of cases during the previous 7-day period. During the week to 1 February 2015, all registered contacts were seen on a daily basis.

SIERRA LEONE

Key performance indicators for the EVD response in Sierra Leone are shown in table 4.

Weekly case incidence increased for the first time this year, from 65 new confirmed cases in the week to 25 January 2015 to 80 new confirmed cases in the week to 1 February.

The west of the country remains the area of most intense transmission. The capital, Freetown, reported 22 new confirmed cases, compared with 20 the previous week. The neighbouring district of Port Loko saw a resurgence of cases, with 36 new confirmed cases compared with 6 in the previous week (figure 1, figure 4).

Western rural district saw a reduction in new cases, with 7 confirmed cases reported compared with 16 the previous week.

A total of 9 out of 14 districts reported at least one new confirmed case in the latest reporting period. Bombali was the only district in the north of the country to report no cases. In the south, Bo, Bonthe, Kailahun, and Pujehun all reported no cases. Bonthe, Kailahun and Pujehun have each reported no confirmed cases for more than 42 days (figure 5).

For definitions of key performance indicators see Annex 3. For the lead agencies coordinating the 4 key lines of action see Annex 2. *A different time period is used for Liberia. #Data from Guinea includes confirmed and probable cases. ‡The percentage of cases for which isolation is not recorded is 4–12% in Guinea, 48–66% in Liberia, and 30–35% in Sierra Leone. ##The percentage of hospitalized confirmed and probable cases which do not have a final outcome recorded is between 4–5% in Guinea, 19–40% in Liberia and 34–78% in Sierra Leone. **Does not include foreign medical teams. §Out of 34 prefectures in Guinea, 15 counties in Liberia, and 14 districts in Sierra Leone.

Figure 5. Days since last reported confirmed case by district in Guinea, Liberia, and Sierra Leone

COUNTRIES WITH AN INITIAL CASE OR CASES, OR WITH LOCALIZED TRANSMISSION

Six countries (Mali, Nigeria, Senegal, Spain, the United Kingdom and the United States of America) have reported a case or cases imported from a country with widespread and intense transmission.

In the United Kingdom, public health authorities confirmed a case of EVD in Glasgow, Scotland, on 29 December 2014 (table 5). The case was a health worker who returned from volunteering at an ETC in Sierra Leone. The patient was isolated on 29 December and received treatment in London. On 23 January the patient tested negative twice for EVD, and on 24 January the patient was discharged. All contacts have completed 21-day follow-up.

Table 5: Ebola virus disease cases and deaths in the United Kingdom

Country

Cumulative cases

Contact tracing

Confirmed

Probable

Suspect

Deaths

Health-care workers

Contacts under follow-up

Contacts who have completed 21-day follow-up

Date last patient tested negative

Number of days since last patient tested negative

United Kingdom

1

0

0

0

100%

0

55

23/01/2015

11

Data are based on official information reported by ministries of health. These numbers are subject to change due to ongoing reclassification, retrospective investigation and availability of laboratory results.

PREPAREDNESS OF COUNTRIES TO RAPIDLY DETECT AND RESPOND TO AN EBOLA EXPOSURE

The introduction of a case into unaffected countries remains a risk for as long as cases are reported in any country. With adequate levels of preparation, however, such introductions of the disease can be contained with a rapid and adequate response.

WHO’s preparedness activities aim to ensure all countries are ready to effectively and safely detect, investigate and report potential EVD cases, and to mount an effective response. WHO provides this support through country visits by preparedness support teams (PSTs), direct technical assistance to countries, and the provision of technical guidance and tools.

Tools and resources for preparedness

Building on existing national and international preparedness efforts, a set of tools has been developed to support any country to identify opportunities for improvements to intensify and accelerate their readiness. The WHO EVD Preparedness Checklist identifies 11 key components and tasks for countries preparing their health systems to identify, detect and respond to EVD. The 11 components include: overall coordination, rapid response, public awareness and community engagement, infection prevention and control, case management, safe burials, epidemiological surveillance, contact tracing, laboratory capacity, and capacity building for points of entry. A revised list of technical guidelines and related training materials by preparedness component has been finalized and can be found on the revised WHO preparedness website.

Priority countries in Africa

The initial focus of support by WHO and partners is on highest priority countries – Côte d’Ivoire, Guinea Bissau, Mali and Senegal – followed by high priority countries – Burkina Faso, Benin, Cameroon, Central African Republic, Democratic Republic of the Congo, Ethiopia, Gambia, Ghana, Mauritania, Nigeria, South Sudan, Niger and Togo. The criteria used to prioritize countries include geographical proximity to affected countries, trade and migration patterns, and strength of health systems.

Since 20 October 2014, PSTs have provided technical support in 14 countries: Benin, Burkina Faso, Cameroon, Central African Republic, Côte d'Ivoire, Ethiopia, Gambia, Ghana, Guinea Bissau, Mali, Mauritania, Niger, Senegal and Togo. Technical working group meetings, field visits, high-level exercises and field simulations have helped to identify key areas for improvement. Each country has a tailored 90-day plan to strengthen operational readiness. WHO and partners are deploying staff to the 14 countries to assist with the implementation of 90-day plans.

A consultative meeting between WHO and partners on EVD preparedness and readiness took place in Geneva between 14 and 16 January. At the meeting an in-depth review of the consolidated checklist for Ebola Preparedness highlighted key gaps and areas to be addressed, including community engagement, infection prevention and control, contact tracing and logistics. A dashboard was also presented which allowed partners to accurately target needs and gaps. This will be used to support in-country preparedness efforts by national authorities. In the coming months, WHO will organize follow up missions to assess progress against 90-day plans, conduct simulation exercises in collaboration with partners, complete the provision of Personal Protective Equipment (PPE) to all fourteen countries, and coordinate WHO and partner engagement with countries. Participants agreed on an action plan and timeline for moving ahead.

Following PST missions, countries that share borders with the countries with intense transmission have taken additional action to prepare for an imported case.

Follow-up EVD preparedness team visits are planned for Côte d’Ivoire (8–15 February), Mali (18–25 February), Senegal (16–23 February) and Guinea Bissau (22–28 February) to support the implementation of country plans and to strengthen cross-border initiatives.

Preparedness in the rest of the world

Beyond the focus on priority countries in Africa, significant efforts have been made in all WHO Regions to strengthen Ebola preparedness. Assessments in several countries in all Regions found that there are still significant gaps and needs related to risk communication, infection prevention and control, laboratory infrastructure, case management and points of entry. There is also a need for standard operating procedures for rapid response teams. Globally, more than 110 countries have been supported to strengthen their public health response capacities in relation to EVD. Regional Offices have already, or are in the process of, conducting regional/subregional training workshops on risk communication, laboratory testing and biosafety, infection prevention and control, and case management. At the country level WHO has also supported the organization of national workshops and simulation exercises to continue to address these gaps.

A global strategy for personal protective equipment and infection control supplies has been developed and supplies have been or are being procured and strategically deployed/stockpiled to ensure their availability in the event of importation in any country of the world.

ANNEX 1: CATEGORIES USED TO CLASSIFY EBOLA CASES

Ebola virus disease case-classification criteria

Classification

Criteria

Suspected

Any person, alive or dead, who has (or had) sudden onset of high fever and had contact with a suspected, probable or confirmed Ebola virus disease (EVD) case, or a dead or sick animal OR any person with sudden onset of high fever and at least three of the following symptoms: headache, vomiting, anorexia/loss of appetite, diarrhoea, lethargy, stomach pain, aching muscles or joints, difficulty swallowing, breathing difficulties, or hiccup; or any person with unexplained bleeding OR any sudden, unexplained death.

Probable

Any suspected case evaluated by a clinician OR any person who died from ‘suspected’ EVD and had an epidemiological link to a confirmed case but was not tested and did not have laboratory confirmation of the disease.

Confirmed

A probable or suspected case is classified as confirmed when a sample from that person tests positive for EVD in the laboratory.

ANNEX 2: COORDINATION OF THE EBOLA RESPONSE ALONG 4 LINES OF ACTION

Lines of action

Lead agency

Case management

WHO

Case finding, lab and contact tracing

WHO

Safe and dignified burials

International Federation of Red Cross and Red Crescent Societies (IFRC)

Community engagement and social mobilization

UNICEF

ANNEX 3: DEFINITIONS OF KEY PERFORMANCE INDICATORS

Response monitoring indicators are calculated using the following numerators and denominators:

Indicator

Numerator

Numerator source

Denominator

Denominator source

Cases and deaths

Number of confirmed cases

# of confirmed cases

Daily country situation reports

N/A

N/A

Number of confirmed deaths

# of confirmed deaths

Daily country situation reports

N/A

N/A

Number of confirmed deaths that occurred in the community

# of deaths in the community with positive EVD swab results

Guinea: Weekly country situation reports

Liberia: UNMEER

Sierra Leone: Ministry of Health / National Ebola Response Centre

N/A

N/A

Contact tracing

Percent of new confirmed cases from registered contacts

# of new confirmed cases registered as a contact (includes probable cases in Guinea)

Guinea: Weekly country situation reports

Liberia: Incident Management System

Sierra Leone: Weekly Ministry of Health surveillance report

Number of new confirmed cases (includes probable cases in Guinea)

Daily country situation reports

Isolation

Time between symptom onset and case isolation (days)

Time between symptom onset and isolation of confirmed or probable cases (geometric mean number of days)

Clinical investigation records

N/A

N/A

Outcome of treatment

Case fatality rate (among hospitalized cases)

# of deaths among hospitalized cases (confirmed or probable)

Clinical investigation records

# of hospitalized cases (confirmed or probable) with a definitive survival outcome recorded